Peak Health · 1 day ago
Clinical Quality Specialist
Morgantown, WV
Full-time
Hybrid
Mid, Senior Level
4+ years expPeak Health is seeking a Clinical Quality Specialist to join their quality team. The role involves overseeing performance improvement activities, ensuring regulatory compliance, and supporting the HEDIS program through medical record retrieval and abstraction. The specialist will also be responsible for performance monitoring, data analysis, and collaborating with management to implement quality initiatives.
FinanceProperty & Casualty InsuranceHealth InsuranceFinancial ServicesInsurance
Responsibilities
Plan, design, implement, and maintain a comprehensive program of continuous quality improvement (CQI) through HEDIS compliance rate tracking, trending and analysis as well as identifying existing challenges, inefficiencies and areas in need of improvement or intervention3
Assume accountability for HEDIS/Stars improvement activities including medical record review, chart collection, and member or provider interventions or education to improve HEDIS compliance rates for Medicare HEDIS/STARS measures
Assist in preparing the annual QI evaluation report and plan/program documents
Review medical records and other documentation to ensure quality care is being provided
Ensure workflows, policies, procedures, regulatory and accreditation standards are implemented and maintain compliance for clinical programs
Investigate potential quality of care issues that may affect the quality or safety of the health of members
Evaluate reports for continued compliance with clinical quality requirements
Actively participate in quality committee, assist in developing annual work plans, program descriptions, and evaluations
Qualification
Required
Current unencumbered licensure with the WV Board of Registered Nurse Professional Nurses, or appropriate state board where services will be provided, as a Registered Nurse professional OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) AND Four (4) years of healthcare clinical experience
Bachelor's degree in healthcare or business-related field AND Six (6) years healthcare quality management or performance improvement in a health plan, hospital, or physician practice
Demonstrated knowledge of CMS regulatory and contractual documents; knowledge of Medicare Advantage, URAC, and/or NCQA accreditation standards, including HEDIS/STARS
Excellent written and oral communication
Problem solving capabilities to drive improved efficiencies and customer satisfaction
Attention to detail
Proficiency with Microsoft Office
Preferred
Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma; Currently enrolled in a BSN program and BSN completion within three (3) years of hire
Managed Care knowledge or experience
Three (3) years Quality Management, Quality Improvement or Process Improvement Experience
Knowledge of CMS guidelines, regulations, NCQA® and HEDIS®
Thorough knowledge of Performance Improvement Projects (PIPs) and is able to apply that knowledge in PIP writing development, update, and analysis of data in PIPs
Able to work with large data sets and analyze information and provide recommendations
Medicare experience preferred
Company
Peak Health
Peak Health is a health insurer that offers health insurance.
51-200 employees
Funding
Current Stage
Growth StageLeadership Team
Ben Gerber
Chief Executive Officer
Brian Stilwell
VP of Finance / CFO
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